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Bose T, Borrow R, Arkwright PD. Impact of rotavirus vaccination on diarrheal disease burden of children in South America. Expert Rev Vaccines 2024; 23:606-618. [PMID: 38813689 DOI: 10.1080/14760584.2024.2360212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/22/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Rotavirus is a leading cause of severe diarrheal disease and death in children under five years of age worldwide. Vaccination is one of the most important public health interventions to reduce this significant burden. AREAS COVERED This literature review examined vaccination coverage, hospitalization rate, mortality, genotypic distribution, immunogenicity, cost-effectiveness, and risk versus benefit of rotavirus vaccination in children in South America. Nine out of twelve countries in South America currently include a rotavirus vaccine in their national immunization program with coverage rates in 2022 above 90%. EXPERT OPINION Introduction of the rotavirus vaccination has led to a marked reduction in hospitalizations and deaths from diarrheal diseases in children under 5 years, particularly infants under 1 year, in several South American countries. In Brazil, hospitalizations decreased by 59% and deaths by 21% (30-38% in infants). In Peru, hospitalizations in infants fell by 46% and deaths by 37% (56% in infants). Overall, data suggest that rotavirus vaccination has reduced rotavirus deaths by 15-50% in various South American countries. There is some evidence that immunity wanes after the age of 1-year old. Ongoing surveillance of vaccine coverage and changes in morbidity and mortality is important to maximize protection against this disease.
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Affiliation(s)
- Tanmoy Bose
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Ray Borrow
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester Medical Microbiology Partnership, Manchester Royal Infirmary, Manchester, UK
| | - Peter D Arkwright
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
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Juvakoski A, Rantanen H, Mulas M, Corona F, Vahala R, Varis O, Mellin I. Evidence of waste management impacting severe diarrhea prevalence more than WASH: An exhaustive analysis with Brazilian municipal-level data. WATER RESEARCH 2023; 247:120805. [PMID: 37976622 DOI: 10.1016/j.watres.2023.120805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
Adequate housing protects from diarrhea, which is a substantial health concern in low- and middle-income countries. The purpose of this study was to quantify the relationship between severe diarrhea and housing features at the municipal level to help in public health planning. Regression analyses were performed on annual (2000-2012) datasets on Brazilian municipalities (5570) in six household feature categories (e.g., waste management) and four severe diarrhea outcomes (e.g., diarrhea deaths of under-5 children). Household data were not available elsewhere of this magnitude and granularity, highlighting the scientific value-add of this study. Municipalities were clustered prior to regression analysis because of data heterogeneity. The compositional household feature data were also subjected to principal component analysis to diminish feature variable multicollinearity. The highest explanatory power was found for diarrhea deaths of under-5 children (R2 = 10-22 %), while those in the over-5 population were the least best explained (R2 = 0.3-7 %). Household features predicted diarrhea outcomes more accurately in the "advanced" housing municipality cluster (R2 = 16-22 %) than in the "mid-level" (R2 = 7-20 %) and "basic" (R2 = 6-12 %) ones (over-5 diarrhea deaths excluded). Under-5 children's diarrhea death prevalence was three times higher in the "basic" cluster than in the "advanced" cluster. Importantly, the impact of waste management was overall the largest of all household features, even larger than those of WASH, i.e., water supply, sanitation, and household drinking water treatment. This is surprising in the context of existing literature because WASH is generally regarded as the most important household factor affecting gastrointestinal health. In conclusion, public health interventions could benefit from customizing interventions for diarrhea outcomes, municipality types, and household features. Waste management's identified stronger association with diarrhea compared to WASH may have important implications beyond the water field and Brazil.
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Affiliation(s)
- Anni Juvakoski
- Department of Built Environment, Aalto University, PO Box 15200, FI-00076, Aalto, Finland.
| | | | - Michela Mulas
- Department of Built Environment, Aalto University, PO Box 15200, FI-00076, Aalto, Finland; Department of Teleinformatics Engineering, Federal University of Ceará, Campus do Pici, Fortaleza, Brazil
| | - Francesco Corona
- Department of Chemical and Metallurgical Engineering, Aalto University, PO Box 16100, Espoo, FI-00076, Aalto, Finland
| | - Riku Vahala
- Department of Built Environment, Aalto University, PO Box 15200, FI-00076, Aalto, Finland
| | - Olli Varis
- Department of Built Environment, Aalto University, PO Box 15200, FI-00076, Aalto, Finland
| | - Ilkka Mellin
- Department of Mathematics and Systems Analysis, Aalto University, PO Box 11100, FI-00076, Aalto, Finland
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Mwangi PN, Page NA, Seheri ML, Mphahlele MJ, Nadan S, Esona MD, Kumwenda B, Kamng'ona AW, Donato CM, Steele DA, Ndze VN, Dennis FE, Jere KC, Nyaga MM. Evolutionary changes between pre- and post-vaccine South African group A G2P[4] rotavirus strains, 2003-2017. Microb Genom 2022; 8. [PMID: 35446251 PMCID: PMC9453071 DOI: 10.1099/mgen.0.000809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The transient upsurge of G2P[4] group A rotavirus (RVA) after Rotarix vaccine introduction in several countries has been a matter of concern. To gain insight into the diversity and evolution of G2P[4] strains in South Africa pre- and post-RVA vaccination introduction, whole-genome sequencing was performed for RVA positive faecal specimens collected between 2003 and 2017 and samples previously sequenced were obtained from GenBank (n=103; 56 pre- and 47 post-vaccine). Pre-vaccine G2 sequences predominantly clustered within sub-lineage IVa-1. In contrast, post-vaccine G2 sequences clustered mainly within sub-lineage IVa-3, whereby a radical amino acid (AA) substitution, S15F, was observed between the two sub-lineages. Pre-vaccine P[4] sequences predominantly segregated within sub-lineage IVa while post-vaccine sequences clustered mostly within sub-lineage IVb, with a radical AA substitution R162G. Both S15F and R162G occurred outside recognised antigenic sites. The AA residue at position 15 is found within the signal sequence domain of Viral Protein 7 (VP7) involved in translocation of VP7 into endoplasmic reticulum during infection process. The 162 AA residue lies within the hemagglutination domain of Viral Protein 4 (VP4) engaged in interaction with sialic acid-containing structure during attachment to the target cell. Free energy change analysis on VP7 indicated accumulation of stable point mutations in both antigenic and non-antigenic regions. The segregation of South African G2P[4] strains into pre- and post-vaccination sub-lineages is likely due to erstwhile hypothesized stepwise lineage/sub-lineage evolution of G2P[4] strains rather than RVA vaccine introduction. Our findings reinforce the need for continuous whole-genome RVA surveillance and investigation of contribution of AA substitutions in understanding the dynamic G2P[4] epidemiology.
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Affiliation(s)
- Peter N Mwangi
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa
| | - Nicola A Page
- Centre for Enteric Disease, National Institute for Communicable Diseases, Private Bag X4, Sandringham, 2131, Johannesburg, South Africa.,Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, 0007, Pretoria, South Africa
| | - Mapaseka L Seheri
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa
| | - M Jeffrey Mphahlele
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa.,Office of the Deputy Vice Chancellor for Research and Innovation, North-West University, Potchefstroom 2351, South Africa.,South African Medical Research Council, Pretoria 0001, South Africa
| | - Sandrama Nadan
- Centre for Enteric Disease, National Institute for Communicable Diseases, Private Bag X4, Sandringham, 2131, Johannesburg, South Africa
| | - Mathew D Esona
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa
| | - Benjamin Kumwenda
- Department of Biomedical Sciences, School of Life Sciences and Applied Health Professions, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Arox W Kamng'ona
- Department of Biomedical Sciences, School of Life Sciences and Applied Health Professions, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Celeste M Donato
- Department of Medical Laboratory Sciences, School of Life Sciences and Applied Health Professions, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre3, Malawi.,Enteric Diseases Group, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Melboune 3052, Australia.,Department of Paediatrics, the University of Melbourne, Parkville 3010, Australia
| | - Duncan A Steele
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa
| | - Valantine N Ndze
- Faculty of Health Sciences, University of Buea, P.O Box 63 Buea, Cameroon
| | - Francis E Dennis
- Department of Electron Microscopy and Histopathology, Noguchi Memorial Institute for Medical Research, University of Ghana, P.O Box LG581, Legon, Ghana
| | - Khuzwayo C Jere
- Center for Global Vaccine Research, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, L697BE, Liverpool, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre 312225, Malawi
| | - Martin M Nyaga
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa
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Isanaka S, Langendorf C, McNeal MM, Meyer N, Plikaytis B, Garba S, Sayinzoga-Makombe N, Soumana I, Guindo O, Makarimi R, Scherrer MF, Adehossi E, Ciglenecki I, Grais RF. Rotavirus vaccine efficacy up to 2 years of age and against diverse circulating rotavirus strains in Niger: Extended follow-up of a randomized controlled trial. PLoS Med 2021; 18:e1003655. [PMID: 34214095 PMCID: PMC8253401 DOI: 10.1371/journal.pmed.1003655] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Rotavirus vaccination is recommended in all countries to reduce the burden of diarrhea-related morbidity and mortality in children. In resource-limited settings, rotavirus vaccination in the national immunization program has important cost implications, and evidence for protection beyond the first year of life and against the evolving variety of rotavirus strains is important. We assessed the extended and strain-specific vaccine efficacy of a heat-stable, affordable oral rotavirus vaccine (Rotasiil, Serum Institute of India, Pune, India) against severe rotavirus gastroenteritis (SRVGE) among healthy infants in Niger. METHODS AND FINDINGS From August 2014 to November 2015, infants were randomized in a 1:1 ratio to receive 3 doses of Rotasiil or placebo at approximately 6, 10, and 14 weeks of age. Episodes of gastroenteritis were assessed through active and passive surveillance and graded using the Vesikari score. The primary endpoint was vaccine efficacy of 3 doses of vaccine versus placebo against a first episode of laboratory-confirmed SRVGE (Vesikari score ≥ 11) from 28 days after dose 3, as previously reported. At the time of the primary analysis, median age was 9.8 months. In the present paper, analyses of extended efficacy were undertaken for 3 periods (28 days after dose 3 to 1 year of age, 1 to 2 years of age, and the combined period 28 days after dose 3 to 2 years of age) and by individual rotavirus G type. Among the 3,508 infants included in the per-protocol efficacy analysis (mean age at first dose 6.5 weeks; 49% male), the vaccine provided significant protection against SRVGE through the first year of life (3.96 and 9.98 cases per 100 person-years for vaccine and placebo, respectively; vaccine efficacy 60.3%, 95% CI 43.6% to 72.1%) and over the entire efficacy follow-up period up to 2 years of age (2.13 and 4.69 cases per 100 person-years for vaccine and placebo, respectively; vaccine efficacy 54.7%, 95% CI 38.1% to 66.8%), but the difference was not statistically significant in the second year of life. Up to 2 years of age, rotavirus vaccination prevented 2.56 episodes of SRVGE per 100 child-years. Estimates of efficacy against SRVGE by individual rotavirus genotype were consistent with the overall protective efficacy. Study limitations include limited generalizability to settings with administration of oral polio virus due to low concomitant administration, limited power to assess vaccine efficacy in the second year of life owing to a low number of events among older children, potential bias due to censoring of placebo children at the time of study vaccine receipt, and suboptimal adapted severity scoring based on the Vesikari score, which was designed for use in settings with high parental literacy. CONCLUSIONS Rotasiil provided protection against SRVGE in infants through an extended follow-up period of approximately 2 years. Protection was significant in the first year of life, when the disease burden and risk of death are highest, and against a changing pattern of rotavirus strains during the 2-year efficacy period. Rotavirus vaccines that are safe, effective, and protective against multiple strains represent the best hope for preventing the severe consequences of rotavirus infection, especially in resource-limited settings, where access to care may be limited. Studies such as this provide valuable information for the planning of national immunization programs and future vaccine development. TRIAL REGISTRATION ClinicalTrials.gov NCT02145000.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Monica Malone McNeal
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States of America
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Nicole Meyer
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States of America
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Brian Plikaytis
- BioStat Consulting, Jasper, Georgia, United States of America
| | | | | | | | | | | | | | | | - Iza Ciglenecki
- Operational Center Geneva, Médecins Sans Frontières, Geneva, Switzerland
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Justino MCA, Campos EA, Mascarenhas JDP, Soares LS, Guerra SDFS, Furlaneto IP, Pavão MJC, Maciel TS, Farias FP, Bezerra OM, Vinente CBG, Barros RJS, Linhares AC. Rotavirus antigenemia as a common event among children hospitalised for severe, acute gastroenteritis in Belém, northern Brazil. BMC Pediatr 2019; 19:193. [PMID: 31189470 PMCID: PMC6560848 DOI: 10.1186/s12887-019-1535-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/14/2019] [Indexed: 12/24/2022] Open
Abstract
Background Rotavirus antigenemia and RNAemia (the presence of rotavirus RNA in serum) have been commonly identified among paediatric patients with acute gastroenteritis. In this study we examined the association between rotavirus antigenemia and clinical features, and sought to determine the genotypes of rotaviruses detected in paired stool and serum samples. Methods Paired stool and serum samples were obtained from children hospitalised for acute gastroenteritis in Belém, Brazil, between June 2012 and June 2015. The 20-point Vesikari scoring system was used to assess the disease severity upon a retrospective medical record review. Stool and serum samples were primarily screened for the presence of rotavirus antigen using a commercial ELISA assay. The rotavirus isolates from stool and serum samples were genotyped by using the classical reverse-transcriptase polymerase chain reaction (RT-PCR) and/or through nucleotide sequencing of VP4 and VP7 genes. Viral load was estimated using real-time RT-PCR. Results In total rotavirus antigen was detected in 109 (24.2%) stool samples from 451 children, whereas antigenemia occurred in 38.5% (42/109) of these patients. We demonstrated that patients positive for rotavirus RNA in paired stool and serum samples were more likely to have a higher frequency of vomiting episodes in a 24-h period (p = 0.0035). Our findings also suggested that children not vaccinated against rotavirus are more likely to develop antigenemia, as compared to those given at least one vaccine dose (p = 0.0151). G12P [8] and G2P [4] genotypes were predominant throughout the study period, accounting for 52.3% (57/109) and 27.5% (30/109) of the typed isolates, respectively. Ten stool-serum pairs could be typed for VP4 and VP7 genes. Seven of these pairs showed concordant results with G2P [4] genotype being detected in stool and serum samples, whereas discrepancies between genotypes (G2P [4]/G2P[NT] and G12P [8]/G2P[NT]) were seen in three pairs. Conclusions Rotavirus antigenemia and RNAemia occur in a significant number of children hospitalised for acute gastroenteritis in Belém, Brazil, and may contribute to a greater disease severity, particularly translated into a greater number of vomiting episodes. This study documented a high concordance of genotypes detected in a subgroup of paired stool and serum samples. Electronic supplementary material The online version of this article (10.1186/s12887-019-1535-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria Cleonice A Justino
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil.
| | - Erika A Campos
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil
| | - Joana D'arc P Mascarenhas
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil
| | - Luana S Soares
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil
| | - Sylvia de Fátima S Guerra
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil
| | | | | | | | | | | | - Caio Breno G Vinente
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil
| | - Rodrigo José S Barros
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil
| | - Alexandre C Linhares
- Instituto Evandro Chagas, Health Surveillance Secretariat, Brazilian Ministry of Health, Rodovia BR 316, Km 7, s/n, Levilândia, Belém, 67.030-000, Brazil
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Emergence of G12P[6] rotavirus strains among hospitalised children with acute gastroenteritis in Belém, Northern Brazil, following introduction of a rotavirus vaccine. Arch Virol 2019; 164:2107-2117. [PMID: 31144039 DOI: 10.1007/s00705-019-04295-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
Species A rotavirus still remains a major cause of acute gastroenteritis in infants and young children. Globally, six genotypes (G1P[8], G2P[4], G3P[8], G4P[8], G9P[8] and G12P[8]) account for >90% of circulating strains; however, genotype G12 in combination with P[6] or P[9] has been detected at increasing rates. We sought to broaden our knowledge about the rotavirus strains circulating during the early post-vaccine-introduction period. Stool samples were obtained from children hospitalised for acute gastroenteritis in Belém, Northern Brazil, from May 2008 to May 2011 and examined by reverse transcription polymerase chain reaction and nucleotide sequencing. A total of 122 out of the original 1076 rotavirus strains were judged to be non-typeable in the first analysis and were therefore re-examined. G2P[4] was the most prevalent genotype (58.0%), followed by G1P[8] (16.9%), and G12P[6] (7.5%). G12P[6] strains were identified at similar rates during the first (2.5%) and second (3.9%) years, and the rate jumped to 15.6% in the third year. Analysis of VP7 sequences of the G12P[6] strains showed that they belonged to lineage III. In addition, co-circulating G12P[6] strains displaying long and short RNA patterns were found to belong to the Wa-like and DS-1-like constellation, respectively. Additional unusual circulating strains G12P[9] and G3P[9] were also identified. This hospital-based study showed a high prevalence of G12P[6] strains in the third year of surveillance. Our results highlight the need for continuous longitudinal monitoring of circulating rotavirus strains after introduction of rotavirus vaccines in Brazil and elsewhere.
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Steele AD, Victor JC, Carey ME, Tate JE, Atherly DE, Pecenka C, Diaz Z, Parashar UD, Kirkwood CD. Experiences with rotavirus vaccines: can we improve rotavirus vaccine impact in developing countries? Hum Vaccin Immunother 2019; 15:1215-1227. [PMID: 30735087 PMCID: PMC6663148 DOI: 10.1080/21645515.2018.1553593] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rotavirus vaccines have been introduced into over 95 countries globally and demonstrate substantial impact in reducing diarrheal mortality and diarrheal hospitalizations in young children. The vaccines are also considered by WHO as “very cost effective” interventions for young children, particularly in countries with high diarrheal disease burden. Yet the full potential impact of rotavirus immunization is yet to be realized. Large countries with big birth cohorts and where disease burden is high in Africa and Asia have not yet implemented rotavirus vaccines at all or at scale. Significant advances have been made demonstrating the impact of the vaccines in low- and lower-middle income countries, yet the modest effectiveness of the vaccines in these settings is challenging. Current research highlights these challenges and considers alternative strategies to overcome them, including alternative immunization schedules and host factors that may inform us of new opportunities.
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Affiliation(s)
- A D Steele
- a Enteric and Diarrheal Diseases , Bill & Melinda Gates Foundation , Seattle , WA , USA
| | - J C Victor
- b Policy, Access and Innovation , Center for Vaccine Innovation and Access , Seattle , WA , USA
| | - M E Carey
- a Enteric and Diarrheal Diseases , Bill & Melinda Gates Foundation , Seattle , WA , USA
| | - J E Tate
- c Division of Viral Diseases , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - D E Atherly
- b Policy, Access and Innovation , Center for Vaccine Innovation and Access , Seattle , WA , USA
| | - C Pecenka
- b Policy, Access and Innovation , Center for Vaccine Innovation and Access , Seattle , WA , USA
| | - Z Diaz
- a Enteric and Diarrheal Diseases , Bill & Melinda Gates Foundation , Seattle , WA , USA
| | - U D Parashar
- c Division of Viral Diseases , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - C D Kirkwood
- a Enteric and Diarrheal Diseases , Bill & Melinda Gates Foundation , Seattle , WA , USA
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Carvalho-Costa FA, de Assis RMS, Fialho AM, Araújo IT, Silva MF, Gómez MM, Andrade JS, Rose TL, Fumian TM, Volotão EM, Miagostovich MP, Leite JPG. The evolving epidemiology of rotavirus A infection in Brazil a decade after the introduction of universal vaccination with Rotarix®. BMC Pediatr 2019; 19:42. [PMID: 30704518 PMCID: PMC6354375 DOI: 10.1186/s12887-019-1415-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/22/2019] [Indexed: 01/15/2023] Open
Abstract
Background Brazil introduced the monovalent rotavirus vaccine (Rotarix®) in 2006. This study aimed to assess the epidemiology and genotype distribution of species-A rotavirus (RVA) in Brazil, comparing the pre- and post-vaccination periods. Methods Laboratory-based RVA surveillance included 866 municipalities in 22 Brazilian states, over a 21-year period. A total of 16,185 children with diarrheal diseases (DD) aged up to 12 years between 1996 and 2005 (pre-vaccination period, n = 7030) and from 2006 to 2017 (post-vaccination period, n = 9155) were enrolled. RVA was detected using ELISA immune assay and/or polyacrylamide gel electrophoresis and genotyped using nested PCR and/or nucleotide sequencing. RVA-positivity and genotypes detection rates were compared in distinct periods and age groups and Rotarix vaccination status. Results RVA-positivity in pre- and post-vaccination periods was, respectively: 4–11 months bracket, 33.3% (668/2006) and 16.3% (415/2547) (p < 0.001); 12–24 months, 28.2% (607/2154) and 22.2% (680/3068) (p < 0.001); 25–48 months, 17.4% (215/1235) and 29.4% (505/1720) (p < 0.001). Genotypes distribution in the pre- and post-vaccination periods was, respectively: G1P [8]/G1P[Not Typed], 417/855 (48.8%) and 118/1835 (6.4%) (p < 0.001); G2P [4]/G2P[NT], 47/855 (5.5%) and 838/1835 (45.7%) (p < 0.001); G3P [8]/G3P[NT], 55/855 (6.4%) and 253/1835 (13.8%) (p < 0.001); G9P [8]/G9P[NT], 238/855 (27.8%) and 152/1835 (8.3%) (p < 0.001); G12P [8]/G129P[NT], 0/871 (0%) and 249/1835(13.6%) (p < 0.001). Concerning infants aged 4–11 months, RVA frequency in fully vaccinated and non-vaccinated individuals was 11.9% (125/1052) and 24.5% (58/237) (p < 0.001), respectively. In children aged 12–24 months, RVA detection rate was 18.1% (253/1395) and 29.6% (77/260) (p < 0.001), for the vaccinated and non-vaccinated individuals, respectively (p < 0.001). Conclusions RVA infection was significantly less frequent in children aged ≤2 years with DD after implementing vaccination, mainly among vaccinated children. It was also observed a decrease of P [8] circulation and emergence of G2P[4] in 2005, and afterwards in the post-vaccine era, with spreading of G12P[8] in 2014–2015 and of G3P[8] in 2017. Continuous RVA surveillance must be carried out in this scenario.
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Affiliation(s)
- Filipe A Carvalho-Costa
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil. .,Laboratory of Epidemiology and Molecular Systematics, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Leonidas Deane, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil. .,Regional Office Fiocruz Piauí. Rua Magalhães Filho, n° 519, Centro/Norte, Teresina, Piauí, Brazil.
| | - Rosane M S de Assis
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alexandre M Fialho
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Irene T Araújo
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelle F Silva
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariela M Gómez
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juliana S Andrade
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tatiana L Rose
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tulio M Fumian
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eduardo M Volotão
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marize P Miagostovich
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Paulo G Leite
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Av. Brasil 4365 Pavilhão Hélio e Peggy Pereira, Manguinhos, Rio de Janeiro, Rio de Janeiro, Brazil
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9
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Ledent E, Arlegui H, Buyse H, Basile P, Karkada N, Praet N, Nachbaur G. Benefit Versus Risk Assessment of Rotavirus Vaccination in France: A Simulation and Modeling Analysis. BioDrugs 2018; 32:139-152. [PMID: 29589230 PMCID: PMC5878204 DOI: 10.1007/s40259-018-0273-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction Two vaccines against rotavirus gastroenteritis (RVGE) in young children, Rotarix and RotaTeq, have been available in Europe since 2006. Vaccination against rotaviruses significantly reduces the burden of RVGE, but it is also associated with a very small increased risk of intussusception. In a benefit–risk analysis, the prevented RVGE burden is weighed against the possible excess of intussusception. Purpose The aim was to compare the estimated benefits and risks of Rotarix vaccination in France. Methods We estimated the benefits (vaccine-preventable RVGE hospitalizations and deaths) and risks (vaccine-caused intussusception hospitalizations and deaths) following two doses of Rotarix in a birth cohort of 791,183 followed for 3–5 years in France. We used data from peer-reviewed clinical and epidemiological studies or publications, and government statistics. Results Within the total number of French children below 5 years of age, we estimate vaccination could prevent a median 11,132 [95% credible interval (CI) 7842–14,408] RVGE hospitalizations and 7.43 (95% CI 3.27–14.68) RVGE deaths. At the same time, vaccination could cause an average of 6.86 (95% CI 2.25–38.37) intussusception hospitalizations and 0.0099 (95% CI 0.0024–0.060) intussusception deaths in the entire French birth cohort of infants below 1 year of age. Therefore, for every intussusception hospitalization and every intussusception death caused by vaccination, 1624 (95% CI 240–5243) RVGE hospitalizations and 743 (95% CI 93–3723) RVGE deaths are prevented, respectively, by vaccination. Conclusions The vaccine-prevented RVGE hospitalizations and deaths (benefit) greatly outweigh the excess potentially vaccination-related cases of intussusception (risk), indicating a favorable benefit–risk balance for Rotarix in France. Electronic supplementary material The online version of this article (10.1007/s40259-018-0273-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Hugo Arlegui
- Clinical Research, NPI and Academic Alliances, Laboratoire GSK, Rueil-Malmaison, France
| | - Hubert Buyse
- Clinical Safety and Pharmacovigilance, GSK, Wavre, Belgium
| | - Peter Basile
- Clinical Safety and Pharmacovigilance, GSK, Wavre, Belgium
| | | | - Nicolas Praet
- Clinical Research and Development, GSK, Wavre, Belgium
| | - Gaëlle Nachbaur
- Pharmaco-Epidemiology and Health Outcomes Research, Laboratoire GSK, Rueil-Malmaison, France
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Al-Aidaroos AY, Standaert B, Meszaros K, Shibl AM. Economic assessment of rotavirus vaccination in Saudi Arabia. J Infect Public Health 2017; 10:564-571. [DOI: 10.1016/j.jiph.2016.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/16/2016] [Accepted: 11/18/2016] [Indexed: 01/03/2023] Open
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Almeida TNV, de Sousa TT, da Silva RA, Fiaccadori FS, Souza M, Badr KR, de Paula Cardoso DDD. Phylogenetic analysis of G1P[8] and G12P[8] rotavirus A samples obtained in the pre- and post-vaccine periods, and molecular modeling of VP4 and VP7 proteins. Acta Trop 2017; 173:153-159. [PMID: 28606817 DOI: 10.1016/j.actatropica.2017.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/31/2017] [Accepted: 06/07/2017] [Indexed: 11/24/2022]
Abstract
Reduction in morbimortality rates for acute gastroenteritis (AGE) by Rotavirus A (RVA) has been observed after the introduction of vaccines, however the agent continues to circulate. The present study described the genomic characterization of the 11 dsRNA segments of two RVA samples G1P[8] obtained in the pre- and post-vaccination periods and one of G12P[8] sample (post-vaccine), compared to Rotarix™ vaccine. Analysis by molecular sequencing of the samples showed that the three samples belonged to genogroup I. In addition, the analysis of VP7 gene revealed that the samples G1 (pre-vaccine), G1 (post-vaccine) and G12 were characterized as lineages II, I and III, respectively. Regarding to VP4 and NSP4 gene it was observed that all samples belonged to lineage III, whereas for VP6 gene, the sample of the pre- and post-vaccine belonged to the lineage IV and I, respectively. Considering the VP7 gene, it was observed high nucleotide and amino acid identity for the two G1 samples when compared to Rotarix™ vaccine and lesser identity for the G12 sample. In relation to antigenic epitope of VP7 greater modifications were observed for the G12 sample in the 7-2 epitope that was confirmed by molecular modeling. On the other hand, for VP4, some changes in the 8-1 and 8-3 antigenic epitopes was observed for the three samples. This data could be interpreted as a low selective pressure exerted by vaccination in relation to G1P[8] samples and lesser protection in relation to G12P[8]. Thus, the continuous monitoring of RVA circulating samples remains important.
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12
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Vieira CB, de Abreu Corrêa A, de Jesus MS, Luz SLB, Wyn-Jones P, Kay D, Rocha MS, Miagostovich MP. The Impact of the Extreme Amazonian Flood Season on the Incidence of Viral Gastroenteritis Cases. FOOD AND ENVIRONMENTAL VIROLOGY 2017; 9:195-207. [PMID: 28160215 DOI: 10.1007/s12560-017-9280-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/27/2017] [Indexed: 06/06/2023]
Abstract
During the Amazonian flood season in 2012, the Negro River reached its highest level in 110 years, submerging residential and commercial areas which appeared associated with an elevation in the observed gastroenteritis cases in the city of Manaus. The aim of this study was to evaluate the microbiological water quality of the Negro River basin during this extreme flood to investigate this apparent association between the illness cases and the population exposed to the contaminated waters. Forty water samples were collected and analysed for classic and emerging enteric viruses. Human adenoviruses, group A rotaviruses and genogroup II noroviruses were detected in 100, 77.5 and 27.5% of the samples, respectively, in concentrations of 103-106 GC/L. All samples were compliant with local bacteriological standards. HAdV2 and 41 and RVA G2, P[6], and P[8] were characterised. Astroviruses, sapoviruses, genogroup IV noroviruses, klasseviruses, bocaviruses and aichiviruses were not detected. Statistical analyses showed correlations between river stage level and reported gastroenteritis cases and, also, significant differences between virus concentrations during this extreme event when compared with normal dry seasons and previous flood seasons of the Negro River. These findings suggest an association between the extreme flood experienced and gastrointestinal cases in the affected areas providing circumstantial evidence of causality between the elevations in enteric viruses in surface waters and reported illness.
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Affiliation(s)
- Carmen Baur Vieira
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (FIOCRUZ), Pavilhão Helio e Peggy Pereira, Avenida Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil.
| | - Adriana de Abreu Corrêa
- Virological Diagnosis Laboratory, Department of Microbiology and Parasitology (MIP), Biomedical Institute, Federal Fluminense University (UFF), Rua Professor Hernani Melo, 101, São Domingos, Niterói, RJ, 24210-130, Brazil
| | - Michele Silva de Jesus
- Laboratory of Infectious Disease Ecology in the Amazon, Leônidas & Maria Deane Institute (ILMD), Oswaldo Cruz Foundation (FIOCRUZ), Rua Terezina, 476, Adrianópolis, Manaus, AM, 69057-070, Brazil
| | - Sérgio Luiz Bessa Luz
- Laboratory of Infectious Disease Ecology in the Amazon, Leônidas & Maria Deane Institute (ILMD), Oswaldo Cruz Foundation (FIOCRUZ), Rua Terezina, 476, Adrianópolis, Manaus, AM, 69057-070, Brazil
| | - Peter Wyn-Jones
- Department of Geography and Earth Sciences (DGES), Aberystwyth University, Penglais Campus, Aberystwyth, Ceredigion, SY23 3DB, UK
| | - David Kay
- Department of Geography and Earth Sciences (DGES), Aberystwyth University, Penglais Campus, Aberystwyth, Ceredigion, SY23 3DB, UK
| | - Mônica Simões Rocha
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (FIOCRUZ), Pavilhão Helio e Peggy Pereira, Avenida Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Marize Pereira Miagostovich
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (FIOCRUZ), Pavilhão Helio e Peggy Pereira, Avenida Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
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Guerra SFS, Soares LS, Lobo PS, Penha Júnior ET, Sousa Júnior EC, Bezerra DAM, Vaz LR, Linhares AC, Mascarenhas JDP. Detection of a novel equine-like G3 rotavirus associated with acute gastroenteritis in Brazil. J Gen Virol 2016; 97:3131-3138. [PMID: 27902376 DOI: 10.1099/jgv.0.000626] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Genotype G3P[8] of rotavirus A (RVA) is detected worldwide, usually associated with Wa-like constellation and exhibiting a long RNA migration pattern. More recently, a novel inter-genogroup, G3P[8] reassortant variant with a short electropherotype, has emerged in Asia, Oceania and Europe, denoting an overall potential of unusual rotavirus strains. During a RVA surveillance in Brazil, G3P[8] strains were found displaying a short electropherotype pattern, which had not been detected before in this region. This study aims to characterize the complete genome of 10 G3P[8] strains detected in the northern region of Brazil. All G3P[8] samples were subjected to partial sequencing, and the whole-genome phylogenetic analysis demonstrated that all strains possessed I2-R2-C2-M2-A2-N1-T2-E2-H2 genotype background, representing reassortants with an equine-like G3 VP7 and amino acid changes in VP4 and VP7 antigenic regions as compared to vaccine strains. Phylogenetic analysis demonstrated high nucleotide identity in almost all RNA segments of G3P[8] DS-1 samples detected in Asia, Oceania and Europe as well as G3P[4] strains in Japan. This study reports a novel, equine-like G3P[8] strain circulating in Brazil and isolated from children hospitalized for severe gastroenteritis, and highlights the complex dynamics of RVA molecular epidemiology. Our findings point to a novel RVA strain emerging in this region, and studies should be done to detect whether this may represent a challenge to current vaccine strategies.
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Affiliation(s)
| | - Luana Silva Soares
- Evandro Chagas Institute, Health Surveillance Secretariat, Belém, Brazil
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14
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Standaert B, Strens D, Li X, Schecroun N, Raes M. The Sustained Rotavirus Vaccination Impact on Nosocomial Infection, Duration of Hospital Stay, and Age: The RotaBIS Study (2005-2012). Infect Dis Ther 2016; 5:509-524. [PMID: 27714677 PMCID: PMC5125134 DOI: 10.1007/s40121-016-0131-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction The benefits of rotavirus (RV) vaccination in developed countries have focused on reductions in mortality, hospitalization and medical visits, and herd protection. We investigated other aspects related to RV-induced nosocomial infection, duration of hospital stay, age shift, and sustained vaccine impact (VI) over time. Method RotaBIS (Rotavirus Belgian Impact Study; ClinicalTrials.gov identifier, NCT01563146) annually collects retrospective data on hospitalization linked to RV testing in children up to 5 years old from 11 pediatric wards located all over Belgium. Data from 2005 to 2012 have been split in pre- (2005–2006) and post-vaccination (2007–2012) period. Information was collected on age, gender, RV test result, nosocomial infection caused by RV and duration of hospital stay. Results Over the 6-year period after the introduction of the RV vaccine, an 85% reduction in nosocomial infections was observed (221 in 2005 to 33 in 2012, p < 0.001). A significant reduction of almost 2 days in average duration of hospital stay per event was observed overall (7.62 days in 2005 to 5.77 days in 2012, p < 0.001). The difference is mainly explained by the higher reduction in number of nosocomial infections. A pronounced age shift (+24%, p < 0.01) of RV nosocomial infection to infants ≤2 months old was observed, increasing with length of post-vaccination period. VI was maintained over the follow-up (±79% VI per birth cohort). A decrease was seen depending on age, 85% (95% CI 76–91%) in the youngest to 63% (95% CI 22–92%) in the oldest age group. Conclusion The higher reduction in nosocomial infection may affect the overall average duration of hospital stay for RV infection. No change in VI by birth cohort, but a reduction by age group was observed. These findings could be important for decision-makers considering the introduction of universal mass RV vaccination programs. Trial registration ClinicalTrials.gov identifier,
NCT01563146. Funding GlaxoSmithKline Biologicals SA (Rixensart, Belgium).
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Affiliation(s)
| | | | - Xiao Li
- GSK Vaccines, Wavre, Belgium
| | - Nadia Schecroun
- Keyrus Biopharma (c/o GSK Vaccines, Wavre, Belgium), Lasne, Belgium
| | - Marc Raes
- Pediatrics, Jessa Hospital, Hasselt, Belgium
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15
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Justino MCA, Brasil P, Abreu E, Miranda Y, Mascarenhas JDP, Guerra SFS, Linhares AC. Clinical Severity and Rotavirus Vaccination among Children Hospitalized for Acute Gastroenteritis in Belém, Northern Brazil. J Trop Pediatr 2016; 62:276-81. [PMID: 26884442 DOI: 10.1093/tropej/fmv098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In March 2006, Brazil introduced the monovalent rotavirus (RV) vaccine (Rotarix™) into the public sector. This study assessed the severity of rotavirus gastroenteritis (RVGE) according to the vaccination status among hospitalized children. We identified 1023 RVGE episodes among not vaccinated (n = 252), partially vaccinated (n = 156) and fully vaccinated (n = 615) children. Very severe gastroenteritis (scored ≥ 15) was reported in 16.7, 17.9 and 13.5% of not vaccinated, partially vaccinated and fully vaccinated children, respectively. There was a trend for a shorter duration of RV diarrhoea among vaccinated children than in not vaccinated children (p = 0.07). A protective effect of vaccination was noted when mean duration of symptoms and hospital stay are analysed, comparing unvaccinated, partially vaccinated and fully vaccinated children (p < 0.05). We showed a vaccination dose effect trend, with fully vaccinated children having less-severe RVGE than not vaccinated and partially vaccinated children.
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Affiliation(s)
- Maria Cleonice A Justino
- Instituto Evandro Chagas, Secretaria de Vigilância em Saúde, Ministério da Saúde, Ananindeua, Pará, Brazil
| | - Patrícia Brasil
- Instituto de Pesquisa Clínica, Fundação Oswaldo Cruz, 21.040-900 Rio de Janeiro, Brazil
| | - Erika Abreu
- Instituto Evandro Chagas, Secretaria de Vigilância em Saúde, Ministério da Saúde, Ananindeua, Pará, Brazil
| | - Yllen Miranda
- Instituto Evandro Chagas, Secretaria de Vigilância em Saúde, Ministério da Saúde, Ananindeua, Pará, Brazil
| | - Joana D'Arc P Mascarenhas
- Instituto Evandro Chagas, Secretaria de Vigilância em Saúde, Ministério da Saúde, Ananindeua, Pará, Brazil
| | - Sylvia F S Guerra
- Instituto Evandro Chagas, Secretaria de Vigilância em Saúde, Ministério da Saúde, Ananindeua, Pará, Brazil
| | - Alexandre C Linhares
- Instituto Evandro Chagas, Secretaria de Vigilância em Saúde, Ministério da Saúde, Ananindeua, Pará, Brazil
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16
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Mathew JL, Vashishtha VM. Time-trend analysis of the impact of universal rotavirus vaccination in Brazil. Indian Pediatr 2016; 53:645-9. [DOI: 10.1007/s13312-016-0904-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Sustained Decrease in Gastroenteritis-related Deaths and Hospitalizations in Children Less Than 5 Years of Age After the Introduction of Rotavirus Vaccination: A Time-Trend Analysis in Brazil (2001-2010). Pediatr Infect Dis J 2016; 35:e180-90. [PMID: 26991061 DOI: 10.1097/inf.0000000000001143] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rotavirus (RV) vaccine, Rotarix, was introduced into the Brazil national immunization program in 2006. To estimate population-level vaccine effect, we conducted a time-trend analysis on all-cause gastroenteritis (GE)-related death certificate-reported deaths (DCRDs), hospital deaths (HDs) and hospitalizations trends in <5-year-olds before and after RV vaccine introduction. METHODS National level all-cause GE-related death certificate [Mortality Information System] and admission (Hospital Information System) data were aggregated and analyzed. Negative-binomial regression models (adjusting for age, year and region) compared DCRDs, HDs and hospitalization trends in <5-year-olds between baseline (2001-2005) and postvaccine introduction periods (Mortality Information System: 2007-2009 and Hospital Information System: 2007-2010). Negative-binomial regression models were fitted to data for each outcome before 2006, and the predicted annual frequencies of each outcome were plotted against corresponding observed annual frequencies. RESULTS During the postvaccine introduction period, there was an overall age-independent GE-related DCRDs reduction (20.9%, P = 0.04) observed in children <5 years of age; a reduction was also seen in infants <1 year of age (20.8%, P = 0.003). Age-independent GE-related HDs and hospitalizations reductions (57.1%, P < 0.0001 and 26.6%, P < 0.0001, respectively) were observed in <5-year-olds; HDs reductions were also observed for each age group (<1-year-olds: 55.0%, P < 0.0001 and 1- to <5-year-olds: 59.5%, P < 0.0001). Observed annual frequencies of GE-related DCRDs, HDs and hospitalizations were lower than the predicted value in each age group in all years after 2006. CONCLUSIONS GE-related DCRDs, HDs and hospitalizations were significantly reduced in <1 and in 1- to <5-year-old Brazilian children after Rotarix introduction, which provides additional evidence of the direct and indirect population-level effect of RV vaccination on GE-related mortality and morbidity in children.
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Vieira CB, de Abreu Corrêa A, de Jesus MS, Luz SLB, Wyn-Jones P, Kay D, Vargha M, Miagostovich MP. Viruses Surveillance Under Different Season Scenarios of the Negro River Basin, Amazonia, Brazil. FOOD AND ENVIRONMENTAL VIROLOGY 2016; 8:57-69. [PMID: 26783031 DOI: 10.1007/s12560-016-9226-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 01/07/2016] [Indexed: 06/05/2023]
Abstract
The Negro River is located in the Amazon basin, the largest hydrological catchment in the world. Its water is used for drinking, domestic activities, recreation and transportation and water quality is significantly affected by anthropogenic impacts. The goals of this study were to determine the presence and concentrations of the main viral etiological agents of acute gastroenteritis, such as group A rotavirus (RVA) and genogroup II norovirus (NoV GII), and to assess the use of human adenovirus (HAdV) and JC polyomavirus (JCPyV) as viral indicators of human faecal contamination in the aquatic environment of Manaus under different hydrological scenarios. Water samples were collected along Negro River and in small streams known as igarapés. Viruses were concentrated by an organic flocculation method and detected by quantitative PCR. From 272 samples analysed, HAdV was detected in 91.9%, followed by JCPyV (69.5%), RVA (23.9%) and NoV GII (7.4%). Viral concentrations ranged from 10(2) to 10(6) GC L(-1) and viruses were more likely to be detected during the flood season, with the exception of NoV GII, which was detected only during the dry season. Statistically significant differences on virus concentrations between dry and flood seasons were observed only for RVA. The HAdV data provides a useful complement to faecal indicator bacteria in the monitoring of aquatic environments. Overall results demonstrated that the hydrological cycle of the Negro River in the Amazon Basin affects the dynamics of viruses in aquatic environments and, consequently, the exposure of citizens to these waterborne pathogens.
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Affiliation(s)
- Carmen Baur Vieira
- Laboratório de Virologia Comparada e Ambiental, Instituto Oswaldo Cruz (IOC), Fundação Oswaldo Cruz (FIOCRUZ), Pavilhão Helio e Peggy Pereira, Avenida Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil.
| | - Adriana de Abreu Corrêa
- Laboratório de Virologia Comparada e Ambiental, Instituto Oswaldo Cruz (IOC), Fundação Oswaldo Cruz (FIOCRUZ), Pavilhão Helio e Peggy Pereira, Avenida Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Michele Silva de Jesus
- Ecologia de Doenças Transmissíveis na Amazônia, Instituto Leônidas e Maria Deane (ILMD), Fundação Oswaldo Cruz (FIOCRUZ), Rua Terezina, 476, Adrianópolis, Manaus, AM, 69057-070, Brazil
| | - Sérgio Luiz Bessa Luz
- Ecologia de Doenças Transmissíveis na Amazônia, Instituto Leônidas e Maria Deane (ILMD), Fundação Oswaldo Cruz (FIOCRUZ), Rua Terezina, 476, Adrianópolis, Manaus, AM, 69057-070, Brazil
| | - Peter Wyn-Jones
- Department of Geography and Earth Sciences (DGES), Aberystwyth University, Penglais Campus, Aberystwyth, Ceredigion, SY23 3DB, UK
| | - David Kay
- Department of Geography and Earth Sciences (DGES), Aberystwyth University, Penglais Campus, Aberystwyth, Ceredigion, SY23 3DB, UK
| | - Marta Vargha
- Department of Water Hygiene, National Institute for Environmental Health, Gyáli út 2-6, Budapest, 1097, Hungary
| | - Marize Pereira Miagostovich
- Laboratório de Virologia Comparada e Ambiental, Instituto Oswaldo Cruz (IOC), Fundação Oswaldo Cruz (FIOCRUZ), Pavilhão Helio e Peggy Pereira, Avenida Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
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Neves MAO, Pinheiro HHC, Silva RSU, Linhares AC, Silva LD, Gabbay YB, Silva MCM, Loureiro ECB, Soares LS, Mascarenhas JDP. High prevalence of G12P[8] rotavirus strains in Rio Branco, Acre, Western Amazon, in the post-rotavirus vaccine introduction period. J Med Virol 2015; 88:782-9. [PMID: 26466923 DOI: 10.1002/jmv.24404] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 12/11/2022]
Abstract
The present study aimed to provide a molecular characterization of circulating rotavirus (RVA) strains in Rio Branco, Acre, in the post-rotavirus vaccination period, particularly with regard to the emerging, increasingly prevalent G12P[8] genotype. A total of 488 fecal specimens from diarrheic and non-diarrheic children were obtained between January and December 2012. RVA detection was initially performed using enzyme-linked immunosorbent assay (ELISA) method, followed by reverse-transcription polymerase chain reaction (RT-PCR) using specific primers. RVA was detected in 18.3% (44/241) of the children with acute diarrhea and in 1.2% (3/247) of the non-diarrheic children (P < 0.001), with overall RVA-positivity of 9.6% (47/488). The most common genotype was G2P[4] with 43.2% (19/44) of the diarrheic cases, followed by G12P[8] (27.3%, 12/44), G3P[6] (18.2%, 8/44), G3P[8] (4.5%, 2/44), and G12P[6] (2.3%, 1/44). G12 samples belonged to lineage III and were from children aged 4-52 months. All of these children had acute diarrhea associated with fever (83.3%, 10/12) and vomiting (66.7%, 8/12). Most of the cases occurred in August (58.3%, 7/12), 75% (9/12) of which having received the full vaccination scheme with Rotarix™. For the first time G12 was reported at relative high prevalence in Brazil. Our findings warrant further monitoring studies on the molecular characterization of circulating RVA strains after rotavirus vaccine introduction in Brazil and elsewhere, since the occurrence of either unusual our emerging genotypes may pose a challenge to vaccination strategies.
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Affiliation(s)
- Mayara A O Neves
- Center for Biological and Health Sciences, University of State of Pará, Pará, Brazil
| | | | - Rita S U Silva
- Municipality Secretary of Health of Rio Branco, Acre, Brazil
| | - Alexandre C Linhares
- Evandro Chagas Institute, Health Surveilance Secretariat, Ministry of Health, Pará, Brazil
| | - Luciana D Silva
- Evandro Chagas Institute, Health Surveilance Secretariat, Ministry of Health, Pará, Brazil
| | - Yvone B Gabbay
- Evandro Chagas Institute, Health Surveilance Secretariat, Ministry of Health, Pará, Brazil
| | - Mônica C M Silva
- Evandro Chagas Institute, Health Surveilance Secretariat, Ministry of Health, Pará, Brazil
| | - Edvaldo C B Loureiro
- Evandro Chagas Institute, Health Surveilance Secretariat, Ministry of Health, Pará, Brazil
| | - Luana S Soares
- Evandro Chagas Institute, Health Surveilance Secretariat, Ministry of Health, Pará, Brazil
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Almeida TNV, Fiaccadori FS, Souza M, Borges AMT, Cardoso DDDDP. Molecular characterization of group A rotavirus before and after the introduction of vaccines in Brazil. Rev Soc Bras Med Trop 2015; 48:599-602. [PMID: 26516971 DOI: 10.1590/0037-8682-0023-2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 05/14/2015] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In this study, the molecular characteristics of group A rotavirus (RVA) were compared in samples obtained before and after RVA vaccine-introduction in Brazil. METHODS Eighty samples were screened for the presence of RVA. Positive samples were molecularly analyzed. RESULTS RVA positivity was 16.9%, with a predominance of G2P[4]. Periods: pre-vaccination: predominance of IId (G1), IId (G2) lineages, and I1 and E1 genotypes; post-vaccination: predominance of Ib (G1), IIa, and IIc (G2) lineages and I2 and E2 genotypes. CONCLUSIONS Although changes in RVA-circulation pattern were observed in the post-vaccination period, it could not be attributed to vaccination process.
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Affiliation(s)
- Tâmera Nunes Vieira Almeida
- Departamento de Microbiologia, Imunologia, Parasitologia e Patologia Geral, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Fabíola Souza Fiaccadori
- Departamento de Microbiologia, Imunologia, Parasitologia e Patologia Geral, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Menira Souza
- Departamento de Microbiologia, Imunologia, Parasitologia e Patologia Geral, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Ana Maria Tavares Borges
- Departamento de Microbiologia, Imunologia, Parasitologia e Patologia Geral, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Divina das Dôres de Paula Cardoso
- Departamento de Microbiologia, Imunologia, Parasitologia e Patologia Geral, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
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Kiulia NM, Hofstra N, Vermeulen LC, Obara MA, Medema G, Rose JB. Global occurrence and emission of rotaviruses to surface waters. Pathogens 2015; 4:229-55. [PMID: 25984911 PMCID: PMC4493472 DOI: 10.3390/pathogens4020229] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 01/03/2023] Open
Abstract
Group A rotaviruses (RV) are the major cause of acute gastroenteritis in infants and young children globally. Waterborne transmission of RV and the presence of RV in water sources are of major public health importance. In this paper, we present the Global Waterborne Pathogen model for RV (GloWPa-Rota model) to estimate the global distribution of RV emissions to surface water. To our knowledge, this is the first model to do so. We review the literature to estimate three RV specific variables for the model: incidence, excretion rate and removal during wastewater treatment. We estimate total global RV emissions to be 2 × 1018 viral particles/grid/year, of which 87% is produced by the urban population. Hotspot regions with high RV emissions are urban areas in densely populated parts of the world, such as Bangladesh and Nigeria, while low emissions are found in rural areas in North Russia and the Australian desert. Even for industrialized regions with high population density and without tertiary treatment, such as the UK, substantial emissions are estimated. Modeling exercises like the one presented in this paper provide unique opportunities to further study these emissions to surface water, their sources and scenarios for improved management.
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Affiliation(s)
- Nicholas M Kiulia
- Department of Fisheries and Wildlife, Michigan State University East Lansing, MI 48824, USA.
- Enteric Viruses Research Group, Institute of Primate Research, P.O Box 24481, 00502 Karen, Nairobi, Kenya.
| | - Nynke Hofstra
- Environmental Systems Analysis Group, Wageningen University, P.O. Box 47, 6700 AA, Wageningen, The Netherlands.
| | - Lucie C Vermeulen
- Environmental Systems Analysis Group, Wageningen University, P.O. Box 47, 6700 AA, Wageningen, The Netherlands.
| | - Maureen A Obara
- Department of Fisheries and Wildlife, Michigan State University East Lansing, MI 48824, USA.
| | - Gertjan Medema
- Faculty of Civil Engineering and Geosciences, Delft University of Technology, P.O. Box 5048, 2600 GA, Delft, the Netherlands.
- KWR Watercycle Research Institute, Groningenhaven 7, 3433 PE, Nieuwegein, The Netherlands.
| | - Joan B Rose
- Department of Fisheries and Wildlife, Michigan State University East Lansing, MI 48824, USA.
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Tort LFL, Victoria M, Lizasoain A A, Castells M, Maya L, Gómez MM, Arreseigor E, López P, Cristina J, Leite JPG, Colina R. Molecular epidemiology of group a rotavirus among children admitted to hospital in Salto, Uruguay, 2011-2012: First detection of the emerging genotype G12. J Med Virol 2015; 87:754-63. [DOI: 10.1002/jmv.24123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2014] [Indexed: 12/13/2022]
Affiliation(s)
| | - Matías Victoria
- Molecular Virology Laboratory, North Regional; University of Republic; Salto Uruguay
| | - Andrés Lizasoain A
- Molecular Virology Laboratory, North Regional; University of Republic; Salto Uruguay
| | - Matías Castells
- Molecular Virology Laboratory, North Regional; University of Republic; Salto Uruguay
| | - Leticia Maya
- Molecular Virology Laboratory, North Regional; University of Republic; Salto Uruguay
| | - Mariela Martínez Gómez
- Laboratory of Comparative and Environmental Virology; Oswaldo Cruz Institute; Rio de Janeiro Brazil
| | | | - Patricia López
- Pediatric Unit of Regional Public Hospital; Salto Uruguay
| | - Juan Cristina
- Molecular Virology Laboratory, Faculty of Sciences; University of Republic; Montevideo Uruguay
| | | | - Rodney Colina
- Molecular Virology Laboratory, North Regional; University of Republic; Salto Uruguay
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da Silva MFM, Rose TL, Gómez MM, Carvalho-Costa FA, Fialho AM, de Assis RMS, de Andrade JDSR, Volotão EDM, Leite JPG. G1P[8] species A rotavirus over 27 years--pre- and post-vaccination eras--in Brazil: full genomic constellation analysis and no evidence for selection pressure by Rotarix® vaccine. INFECTION GENETICS AND EVOLUTION 2015; 30:206-218. [PMID: 25562122 DOI: 10.1016/j.meegid.2014.12.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 11/28/2014] [Accepted: 12/24/2014] [Indexed: 12/26/2022]
Abstract
Epidemiological data on species A rotavirus (RVA) infections have demonstrated the genetic diversity of strains circulating worldwide. Many G and P genotype combinations have been described over the years, varying regionally and temporally, especially in developing countries. However, the most common G and P genotype combinations identified in RVA human strains worldwide are G1P[8], G2P[4], G3P[8], G4P[8] and G9P[8]. RVA genotype G1P[8] strains are responsible for more than 50% of child infections worldwide and component of the two vaccines (Rotarix® [RV1] and RotaTeq® [RV5]) licensed globally. For a better understanding of the evolutionary mechanisms of this genotype in Brazil, phylogenetic analyses based on the 11 RVA genome segments (genomic constellation) from 90 G1P[8] RVA strains collected in two eras - (i) pre-vaccination with RV1 (1996-February 2006); (ii) post-vaccination (March 2006-2013) - in different Brazilian states were performed. The results showed the Wa-like genomic constellation of the Brazilian G1P[8] strains with a I1-R1-C1-M1-A1-N1-T1-E1-H1 specificity, except for two strains (rj14055-07 and ba19030-10) that belong to a I1-R1-C1-M1-A1-N1-T3-E1-H1 genomic constellation, evidencing the occurrence of reassortment (Wa-like×AU-1-like) of the NSP3 gene. Reassortment events were also demonstrated between Brazilian G1P[8] strains and the RV1 vaccine strain in some genes in vaccinated and unvaccinated children. VP7 and VP8* antigenic site analysis showed that the amino acid substitutions observed in samples collected after the introduction of RV1 in Brazil were already detected in samples collected in the 1980s and 1990s, suggesting that mass Brazilian RV1 vaccination had no impact on the diversity observed inside antigenic sites for these two proteins.
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Affiliation(s)
- Marcelle Figueira Marques da Silva
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.
| | - Tatiana Lundgren Rose
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Mariela Martínez Gómez
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Filipe Anibal Carvalho-Costa
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Alexandre Madi Fialho
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Rosane Maria Santos de Assis
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Eduardo de Mello Volotão
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - José Paulo Gagliardi Leite
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
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Gómez MM, Carvalho-Costa FA, Volotão EDM, Rose TL, da Silva MFM, Fialho AM, de Assis RMS, Matthijnssens J, Leite JPG. A decade of G3P[8] and G9P[8] rotaviruses in Brazil: Epidemiology and evolutionary analyses. INFECTION GENETICS AND EVOLUTION 2014; 28:389-97. [DOI: 10.1016/j.meegid.2014.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/09/2014] [Accepted: 05/14/2014] [Indexed: 12/22/2022]
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Mladenova Z, Nawaz S, Ganesh B, Iturriza-Gomara M. Increased detection of G3P[9] and G6P[9] rotavirus strains in hospitalized children with acute diarrhea in Bulgaria. INFECTION GENETICS AND EVOLUTION 2014; 29:118-26. [PMID: 25461849 DOI: 10.1016/j.meegid.2014.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/23/2014] [Accepted: 11/12/2014] [Indexed: 11/30/2022]
Abstract
Rotavirus severe disease in children is now vaccine-preventable and the roll-out of vaccination programs globally is expected to make a significant impact in the reduction of morbidity and mortality in children <5 years of age. Rotavirus is also a pathogen of other mammals and birds, and its segmented RNA genome can lead to the emergence of new or unusual strains in human population via interspecies transmission and reassortment events. Despite the efficacy and impact of rotavirus vaccine in preventing severe diarrhea, the correlates of protection remain largely unknown. Therefore, rotavirus strain surveillance before, during and after the introduction of immunization programs remains a crucial for monitoring rotavirus vaccine efficacy and impact. In this context, molecular characterization of 1323 Bulgarian rotavirus strains collected between June 2010 and May 2013 was performed. A total of 17 strains of interest were analyzed by partial sequence analysis. Twelve strains were characterized as G3P[9] and G6P[9] of potential animal origin. Phylogenetic analysis and comparisons with the same specificity strains detected sporadically between 2006 and 2010 revealed the constant circulation of these unusual human strains in Bulgaria, although in low prevalence, and their increased potential for person-to-person spread.
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Affiliation(s)
- Zornitsa Mladenova
- National Center for Infectious and Parasitic Diseases, Sofia, Bulgaria; Public Health of England, London, United Kingdom.
| | | | | | - Miren Iturriza-Gomara
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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